DIABETES
June 1, 2000

Pancreas Transplant: A Cure for Diabetes?

Type 1 diabetics with kidney disease should strongly consider simultaneous kidney and pancreas transplant.
Diabetes mellitus is the leading cause of irreversible renal (kidney) failure, also known as End Stage Renal Disease (ESRD), in the world's better-fed nations. Disturbingly, the trend is up; over the past decade, the incidence of ESRD attributed to diabetes has grown at an annual rate of more than nine percent. Diabetes mellitus can also cause a host of nerve, vascular and other problems that can result in limb amputation and blindness.

There are two basic types of diabetes: long-duration, non-insulin dependent diabetes (type 2); and insulin-dependent diabetes mellitus (type 1). While both types are equally likely to cause kidney disease and ERSD, type 1 diabetes tends to attract greater attention from the media as well as from medical professionals.

The reason for this is emotional — often, the victims of type 1 diabetes are children and young adults, who are faced with years of regular injections of insulin and whose lives are shortened or terribly damaged by diabetes and its many associated illnesses.

There has been a general outcry for a treatment that offers a cure, rather than simply a way of managing the disease.

The good news about diabetes is that a cure, or something that comes pretty close, may, in fact, already exist: combined kidney and pancreas transplant.

Current Treatment
Standard diabetes treatments focus on slowing the course of some of its worse effects, such as kidney disease and retinopathy, a degenerative eye disease. They do this by controlling high blood pressure, by using insulin and other means to correct imbalances in blood sugar and by reducing the amount of dietary protein that diabetes sufferers take in. Still, no matter how rigidly they follow the complicated regimen prescribed by their doctor and no matter how carefully they monitor their blood glucose levels, type 1 diabetics still face a restricted and often shortened life.

For many diabetics, the day comes when their damaged kidneys are no longer adequately cleaning the blood and they must begin dialysis. Dialysis is a time-consuming and terribly inconvenient process in which waste products are removed from the blood by artificial means. While this can be done in different ways, dialysis patients often face the prospect of traveling to a center for a procedure that can take as much as four or five hours each time, as frequently as several sessions per week.

For diabetics who have reached the ESRD stage, a likely option is kidney transplant. Although a successful kidney transplant can give type 1 diabetic patients a better survival rate than if they had continued with dialysis, it does not stop the progress of the disease. For example, problems with the blood vessels and blood circulation continue to worsen even with a new kidney.

Why do the bad effects of diabetes continue? One reason is that diabetes involves the pancreas as well as the kidney. The pancreas produces insulin, the hormone that regulates how we use glucose, the sugar that is our primary source of energy. When the pancreas malfunctions, diabetes can result. The idea behind combined kidney/pancreas transplant is to both replace kidneys damaged by diabetes and to eliminate abnormal insulin production by providing a healthy pancreas.

Pancreas Transplantation
Even though the concept had been around for decades, it was only in the late 1960s that doctors began to see successful outcomes from combined kidney and pancreas transplants. On the down side, patients who received combined pancreas and kidney transplants did run a greater risk of death during or immediately after surgery than those who undergo kidney transplants alone. This led critics of pancreas transplantation to characterize the procedure as experimental and even dangerous. Gradually, however, the success rate of pancreas transplantation has improved.

Pancreas Transplant Surgery
The main hurdle to overcome for surgeons performing pancreas transplant was determining how and where to drain certain digestive juices from the pancreas. Two methods that were tried and failed. Today, however, surgeons connect the pancreatic duct to the bladder. Unfortunately, during the first year after the operation, this can mean repeated hospitalizations of pancreas transplant recipients for bladder pain, hemorrhage, and urinary infection. Most patients, however, feel that this is an acceptable trade-off, as they no longer have to worry about blood glucose levels. Successful pancreas transplant means freedom from daily burden of balancing diet, exercise and insulin dosage and it has has been enthusiastically welcomed by patients with type 1 diabetes.

The International Pancreas Transplant Registry reported in 1998 that, by the end of 1996, 9,000 pancreas transplants had been reported. For those performed between 1994-1996, one-year pancreas survival rates were 81% for simultaneous pancreas and kidney transplantation, 71% for pancreas after kidney, and 64% for pancreas alone.

This operation is too new to be able to say for sure whether it will help prevent the further progression of diabetic nerve disorders, as well as circulatory disease. However, preliminary studies of patients who have received first kidney and, later, pancreas transplants hold out some hope that it may. Furthermore, a recent study of 500 simultaneous pancreas-kidney transplants done in Wisconsin showed even more encouraging results for this operation. The Wisconsin group attained remarkable survival rates at one, five and ten years of 96.4%, 88.6%, and 76.3%.

Surprisingly, evidence is also mounting that pancreas transplantation may help those with type 2 diabetes as well.

Conclusion
Today's ESRD type 1 diabetic, especially those younger than age 45, with diabetes-related kidney disease should strongly consider simultaneous kidney and pancreas transplant. This procedure has a very high — and rising — success rate and the upside is complete escape from the burden and life constraints caused by this inexorable disease.
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